SOAP Note Documentation PDF
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Uploaded by CelebratedDogwood
Tufts University
Michael Clarke
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Summary
This document provides an introduction to SOAP notes, which are a crucial part of physical therapy documentation. It details the four components of the SOAP note: Subjective, Objective, Assessment, and Plan, and describes their significance in physical therapy. Additionally, it covers tips to improve clarity and objectivity in writing SOAP notes and best practices for documentation.
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SOAP Note Documentation Michael Clarke PT, DPT Board Certified Orthopedic Clinical Specialist (OCS) Fellow of the American Academy of Orthopedic Manual Physical Therapists (FAAOMPT) Learning Objectives 1. List the four components of the SOAP note framework 2. Explain the purpose and signific...
SOAP Note Documentation Michael Clarke PT, DPT Board Certified Orthopedic Clinical Specialist (OCS) Fellow of the American Academy of Orthopedic Manual Physical Therapists (FAAOMPT) Learning Objectives 1. List the four components of the SOAP note framework 2. Explain the purpose and significance of the SOAP note framework in physical therapy documentation 3. Outline the specific information that should be included in each section of a SOAP note What is SOAP Note? Subjective—Hear Me ROS Objective—See/Watch/Move Me Tests Assessment—Figure Me Out Interpret Plan—Help Me Interventionsa , Purpose of a SOAP Note 1. Communication Tool Among Healthcare Providers 2. Continuity of Care and Treatment Planning 3. Legal & Ethical Considerations Subjective 1. Gathering Patient Information History Chief Complaint Subjective Symptoms 2. Statement Sources Patient Caregiver Other Healthcare Providers Medical Records Yat Rom measurements Objective Data Gathered 1. Observations 2. Tests and Measures 3. Clinical Findings 4. Levels of Assistance 5. Interventions Performed and Patient Response tation Assessment Interpre Clinical Reasoning Analyze Subjective and Objective Data Formulate an Opinion Diagnosis Prognosis Treatment Rationale Clinical Impressions Justify Your Decision and Value “The Why” à ICF Model Plan Treatment Plan; Plan of Care Prognosis Interventions Goals Therapy Duration & Frequency Coordination Purposes Future Actions and Follow-Up Aims & Intention Therapist Recall Communication; PT/PTA Demonstrates Skill and Clinical Decision-Making Writing Tips 1. Clarity, Conciseness, and Objectivity 2. Avoid Jargon and Abbreviations 3. Documentation Best Practices Defensible Documentation SOAP Note Format Standardized Structure Types of Patient/Client Notes Initial Exam/Eval Note Daily/Treatment Note Progress/Re-Evaluation Note Follow-up Discharge Note Format Should Flow Related Information in Each Section Case Study of the Lower Extremity S: Patient reported she has a hard time getting out of her as kitchen chair at home; stated her legs feel weak O: Patient required 5 attempts to go sit to stand from standard chair; used 1 arm on arm rest and pulled up with the other arm on a counter; B knee and hip extension strength: 3+/5 MMT Kuna A: Patient’s impairments in lower extremity strength are leading to limitations in sit to stand transfers; this is causing thend decreased functional mobility and poses a safety risk strength- ening P: Will initiate transfer training using multiple surface heights; will work on increasing LE strength What is SOAP Note? Subjective—Hear Me Objective—See/Watch/Move Me Assessment—Figure Me Out Plan—Help Me References American Physical Therapy Association 2018, Documentation: Documentation of a Visit, accessed 23 February 2024, https://www.apta.org/your-practice/documentation/defensible- documentation/elements-within-the-patientclient-management-model/documentation-of-a- visit Kettenbach G, Schlemer SL. Writing Patient/Client Notes: Ensuring Accuracy in Documentation. 5th Edition. F.A. Davis Company; 2016 © All rights reserved.
